<%@ include file="/common/taglibs.jsp"%>

<head>
    <title><fmt:message key="signup.title"/></title>
    <meta name="heading" content="<fmt:message key='signup.heading'/>"/>
</head>

<body id="signup"/>

<div class="separator"></div>

<s:form name="wellnessProfileForm" action="saveWellness" method="post" validate="true">
    <li class="info">
        <fmt:message key="wellness.message"/>
    </li>
<!--
    <li>
        <div>
            <div class="left">
                <s:textfield key="main.firstname" theme="xhtml" required="true" cssClass="text medium"/>
            </div>
            <div>
                <s:textfield key="main.lastname" theme="xhtml" required="true" cssClass="text medium"/>
            </div>
        </div>
    </li>

    <li>
        <div>
            <div class="left">
                <s:textfield key="main.phone" theme="xhtml" required="true" cssClass="text medium"/>
            </div>
            <div>
                <s:textfield key="main.phone2" theme="xhtml" cssClass="text medium"/>
            </div>
        </div>
    </li>

    <li>
        <label class="desc"><fmt:message key="main.address"/></label>
        <div class="group">
            <div>
                <s:textfield key="main.address" theme="xhtml" cssClass="text large" labelposition="bottom"/>
            </div>
            <div class="left">
                <s:textfield key="main.city" theme="xhtml" required="true" cssClass="text medium" 
                    labelposition="bottom"/>
            </div>
            <div>
                <s:textfield key="main.state" theme="xhtml" required="true" cssClass="text state" 
                    labelposition="bottom"/>
            </div>
            <div class="left">
                <s:textfield key="main.zipcode" theme="xhtml" required="true" cssClass="text medium" 
                    labelposition="bottom"/>
            </div>           
        </div>
    </li>
-->
    <s:textfield key="main.companyname" required="true" cssClass="text large"/>
	
	<s:textfield key="main.physicianname" required="true" cssClass="text large"/>

	<s:textfield key="main.healthplanname" required="true" cssClass="text large"/>
	<li>
        <div>
            <div class="left">
                <s:textfield key="main.clientid" theme="xhtml" required="true" cssClass="text medium"/>
            </div>
            <div>
                <s:textfield key="main.groupnumber" theme="xhtml" cssClass="text medium"/>
            </div>
        </div>
    </li>
<!-- 	
	<li>
        <div>
            <div class="left">
                <s:textfield key="pwp.recorddate" theme="xhtml" required="true" cssClass="text medium"/>
            </div>
            <div>
                <s:textfield key="main.birthdate" theme="xhtml" cssClass="text medium"/>
            </div>
        </div>
    </li>
 -->    
	<li>
        <div>
            <div class="left">
                <s:textfield key="main.race" theme="xhtml" required="true" cssClass="text medium"/>
            </div>
            <div>
                <s:textfield key="main.gender" theme="xhtml" cssClass="text medium"/>
            </div>
<!--        
		    <div>
                <s:textfield key="pwp.framesize" theme="xhtml" cssClass="text medium"/>
            </div>
             -->
        </div>
    </li>
<!-- 
	<li>
        <div>
            <div class="left">
                <s:textfield key="pwp.height" theme="xhtml" required="true" cssClass="text medium"/>
            </div>
            <div>
                <s:textfield key="pwp.weight" theme="xhtml" cssClass="text medium"/>
            </div>
            <div>
                <s:textfield key="pwp.age" theme="xhtml" cssClass="text medium"/>
            </div>
        </div>
    </li>
 -->    
    <div class="separator"></div>
    <li class="info">
        <fmt:message key="wellness.questions"/>
    </li>
    
    
    <li class="buttonBar bottom">
        <s:submit key="button.save" cssClass="button"/>
        <s:submit key="button.cancel" name="cancel" cssClass="button"/>
    </li>
</s:form>

<script type="text/javascript">
    Form.focusFirstElement(document.forms["wellnessProfileForm"]);
</script>
